A social worker assigned to the ‘Baby Nicola’ case has since been sacked by Sunderland City Council, while others involved in the ‘Baby Penny’ case have faced formal disciplinary procedures.

The reviews scrutinised the roles played by a number of health professionals and organisations – including maternity services, health visitors and social workers – involved in the welfare of each child.

While the reports highlight problems as well as good work by the organisations involved with their families before their birth and after they were born, both documents highlighted the poor state the council’s social services were in at the time.

Officials have said action plans are in place to help ensure such cases don’t happen again.

Recommendations centre on improved management and supervision, guidance on when information should be followed up and bringing together agencies to share details and concerns.

There will also be greater emphasis on asking questions of families, as the cases looked at how more should have been posed to put together a fuller picture of the parents’ circumstances.

The officers said they did not always have time to be “curious” because of their large workloads.

The reviews acknowledged as contributing factors a high turnover of staff, pressure of work leading to a lack of checks on assessments being signed off by bosses, volume of work reducing the amount of time the managers could spend on monitoring and closing cases.

Government cuts, which have impacted on support staff and recruitment issues, have previously been noted by the council, while a failure on the part of managers and leading councillors was raised by Ofsted inspectors. Steve Walker, the council’s director of children’s services, said: “We take the findings of these reviews seriously and our thoughts are very much with the families.

“While there is no suggestion that the lack of action on the part of professionals contributed directly to the sad circumstances in either case, it is important that we recognise that there are areas where would could have done better. “As a council we fully accept the recommendations and acknowledge that there are areas where we need to significantly improve safeguarding services. “We had already recognised the need for a significant amount of work to improve safeguarding and begun to take action to address the issues it highlighted prior to the publication of July’s Ofsted report.” Colin Morris, the independent chairman of Sunderland Safeguarding Children Board who is a spokesman for the organisations brought together under the reviews, said the reports were “hard documents to read” because of their upsetting nature.

He added: “While recognising that Baby Penny’s death was a tragic accident and that neither her death nor Baby’s Nicola’s injuries were the direct result of any failings on the part of professionals, we do not shy away from the criticisms raised by the reports and have taken strong action to address them.

“The themes that run through both of these cases are pretty common.

“These are not things I can attempt to defend because poor communication, people failing to escalate and get the right answers, not following proper procedure and policies cannot be defended.

“Our job is to look at what we can do to bring about changes.”

Six more case reviews are due to be published by the safeguarding board, with the report into ‘Baby Penny’ stating there was a delay in the publication of the report because of the large number of cases being reviewed in Sunderland.

Mr Morris added: “There are different reasons why they take some time.

“Sometimes it is because they are put forward before a court and subject to criminal proceedings or are going through the coroner’s process.”